Socioeconomic, demographic, and cultural determinants of delivery by caesarian section in Ethiopia: Evidence from Ethiopia Mini Demographic and Health Survey 2019

Delivery by cesarean section is a surgical procedure of delivery to a newborn baby, and the process is applied when vaginal delivery is unsafe. This study aims to identify the socioeconomic, demographic, and cultural factors that significantly impact the delivery by caesarean section. The 2019 Ethiopia Mini Demographic and Health Survey (2019 EMDHS) data were used to conduct this research, and this study considered 2872 ever-married women all over the country who delivered in the clinical setting. Firstly, a frequency distribution table has been constructed to understand the characteristics of the selected explanatory and study variables. Then Chi-square test identifies the association between various socioeconomic and demographic factors and delivery by the caesarian section. Finally, the Binary Logistic Regression was used to determine the factors that substantially impact the caesarian section among women in Ethiopia. The Chi-square test of association showed that mother’s age, type of residence, highest education level, religion, socioeconomic status, total children ever born, use of contraception, age of mothers at first birth, and preceding birth interval were significantly associated with the caesarian section. The multivariate binary logistic regression analysis revealed that the mother’s current age (Age Group: 31–40; Odds Ratio: 2.487, p<0.05) and religion (Muslim; Odds Ratio: 0.599, p<0.05) substantially influenced the study feature. Moreover, the highest educational level (Secondary and higher; Odds Ratio: 1.581, p<0.05), and the preceding birth interval (>40 months; Odds Ratio: 0.682, p<0.05) were also found to have considerable impacts on the caesarian section. Furthermore, the total number of children ever born (>5; Odds Ratio: 0.498, p<0.05) significantly impacts the delivery by caesarean section in Ethiopia. This study’s results would be useful to policymakers to take necessary steps to reduce unnecessary delivery by caesarian section and ensure a safer newborn delivery process.


Introduction
Delivery by Cesarean section (DCS) is a life-saving surgical procedure for both the mother and baby and is delivered via an incision in the mother's abdomen. In the past two decades, global a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 Health Survey (2019 EMDHS) along with the Federal Ministry of Health (FMoH) and Central Statistical Agency (CSA), and the overall guidance was provided by the Technical Working Group (TWG). The Data was collected from March to June 2019. The World Bank, the United States Agency for International Development (USAID), and the United Nations Children's Fund (UNICEF) funded the 2019 EMDHS. Technical assistance for the DHS Program was provided by ICF, a USAID-funded project providing technical assistance and support in implementing demographic and health surveys across countries worldwide. All the figures and tables used in this study have been constructed by the authors of this research based on 2019 EMDHS data [23].

Dependent variable
The dependent variable considered in this study was delivery by the caesarian section (No, Yes), a binary variable. Mothers who gave at least one birth with CS were categorized as "Yes", and those with no CS were classified as "No".

Explanatory variables
A total of 13 independent variables have been considered in this study. The explanatory variables were divided into three different groups: socioeconomic, demographic, and cultural features. The socioeconomic variables include socioeconomic status (Poor, Middle, Rich), type of residence (Urban, Rural), and educational level (No education, Primary, Secondary and above). The demographic group consists of the age of the mothers (15-20, 21-30, 31-40, 41-49), total children ever born (1-2, 3-5, >5), sons have died (No, Yes), use of contraception (No, Yes), age of mothers at 1 st birth (10-15, 16-20, 21-25, 26-30, 31-36, 36-44), currently breastfeeding (No, Yes), sex of the child (Male, Female), the child is alive (No, Yes), and preceding birth interval (10-20, 21-30, 31-40, >40). Finally, the cultural feature was the religion (Orthodox, Protestant, Muslim, Other). Initially, the mother's current age, the total number of children ever born, the age of mothers at 1st birth, and the preceding birth interval were discrete numeric variables; later, they were converted to categorical features as mentioned above as the study's dependent variable is a binary categorical variable and make a better presentation of the interpretations.

Study population
The 2019 EMDHS children record data considered a total of 5753 women, of which 2881 gave birth at home, and 2872 delivered their baby at a health facility setting. The study population of this investigation was the women who delivered in the clinical setting (n = 2872) in Ethiopia. These women were asked about DCS, and 12.2% (n = 349) of women were found to give birth by cesarean section (Table 1). This study excluded all women who gave birth at home setting.

Statistical analysis
The data for this study have been extracted from the 2019 Ethiopia Mini Demographic and Health Survey (2019 EMDHS). The total number of respondents to the survey was 5753. This study considered 2872 respondents who gave birth at the health facility setting to assess the impact of demographic, socioeconomic, and cultural factors on DCS. It is observed that 2523 (87.8%) respondents delivered their child in a normal way, and 349 (12.2%) respondents delivered their child in a caesarian way. Initially, 13 explanatory variables were considered in this study that potentially influenced the dependent variable "delivery by caesarian section". Firstly, the frequency distribution of all the dependent and independent variables has been prepared to gain knowledge about the background characteristics of the respondents. Since the outcome variables considered in this study were categorical, the non-parametric statistical approach was applied throughout the study. The non-parametric Chi-square (χ2) test was applied to identify the significant association between the delivery by caesarian section and a variety of independent variables. The explanatory variables found significant in bivariate analysis were

Ethical consideration
The Demographic and Health Survey (DHS) program granted this research to collect Ethiopian Mini Demographic and Health Survey 2019 (EMDHS 2019) data after carefully reviewing the short description provided by the authors, and high confidentiality was maintained when dealing with the data. The ethical approval for EMDHS 2019 was obtained from the Ministry of Science and Technology, IFC International's Institutional Review Board, the Ethiopian Health and Nutrition Institute Review Board, and the CDC. Informed consent was obtained from the respondents when collecting the data, ensuring the information would be kept confidential [24]. A frequency distribution table has been constructed in univariate analysis to understand the characteristics of Ethiopian women's demographic, socioeconomic, and cultural conditions and is presented in Table 1. From Table 1, it is observed that most respondents belong to the age group 21-30 years (n = 1722, 60%), and most of the respondents (1768, 61.6%) live in rural areas. Education is essential for every part of human life, but a high percentage of the mothers (n = 1116, 38.9%) had primary education, followed by illiterate (n = 1066, 37.1%) in Ethiopia. Only a few mothers had secondary and higher education (n = 690, 24%). In the case of religion, Table 1 shows that most of the mothers are Muslim (n = 1303, 45.4%), and about (n = 1112, 38.7%) of the respondents who went to the clinic were rich.

Results
The table illustrates that (n = 1608) 56% of the respondents do not use contraception. A significant number of women (n = 2730, 95.1%) reported that their children were alive. Preceding birth intervals play an important role in the caesarian section among women, and a maximum (n = 1107, 38.5%) of the mothers take 10-20 months from one birth to another. The variable "Age of mothers at first birth" measures the age from when girls begin childbearing. Of the maximum number of respondents (n = 1334, 46.4%) give birth at 16-20 years. The variable socioeconomic condition potentially influences the caesarian section delivery among women  in Ethiopia. In addition to the univariate analysis, the bivariate analysis was performed to test the association between various explanatory variables and delivery by caesarian section among the women in Ethiopia. The Chi-square test was applied to assess these associations and presented in

Factors influencing delivery by caesarian section
The binary logistic regression is used as a multivariate analysis to determine the factors that significantly impact the DCS in Ethiopia and is presented in Table 3. From Table 3, it is observed that the mother's current age significantly influences the DCS.  Table 3 revealed that the mothers' educational level significantly impacts DCS among Ethiopian women. The result showed that the secondary and higher educated respondents have 1.581 times (Odds: 1.581, p<0.05) more odds of DCS than their illiterate counterparts. In addition, religion is found to impact the study variable (p<0.05) significantly, and the people who belong to Orthodox are more prone to give birth by caesarian section. The total number of children born substantially impacts Ethiopia's DCS (Odds: 0.498, p<0,05). The results showed that couples with more than 5 children were 51% less likely to have a child by caesarian section (Odds: 0.49, p<0.05) compared to their counterparts with 1-2 children. The most important factor considered in this study is the age of the mothers at first birth, and this feature is found to have a significant impact on the DCS. The study results showed that the respondents aged 36-44 years have 2.148 times (Odds: 2.148, p<0.05) more risk of having a caesarean child than mothers aged 15-20. Moreover, the variable child is alive had a substantial role in DCS (Odds: 0.488, p<0.05). The preceding birth interval significantly affected DCS (p<0.05). The odds ratio of 0.682 indicates that the couples with preceding birth intervals between babies over 40 months were 31.8% less likely to have a baby with CS than their counterparts of preceding intervals 10-20 months. The Hosmer-Lemeshow test has measured the goodness of fit of the proposed model. The Chi-square statistic and p-value in the Hosmer-Lemeshow goodness of fit test (Chi-square: 5.185, p = 0.788) indicate that the binary logistic regression fits the data well and provides more appropriate outcomes.

Discussion
This study investigated the determinants of DCS among Ethiopian women. It is observed from the results that the mothers' age significantly impacts the DCS, and the age group 31-40 and 41-49 had a higher likelihood of having DCS. This is because a range of diseases could develop within the body of older women, which cause various health complications and lead those women to choose caesarean delivery. Similar to the results of this investigation, Joseph A. Adashek et al. (1993) found that maternal age was significantly associated with DCS [25]. A study conducted in Ontario, Canada, by G. Janoudi, and colleagues revealed that the prevalence of the risk factors of the cesarean section increased with advancing maternal age [26]. Older women (more than 34 years) tend to choose DCS compared to women of younger age [27]. Moreover, an investigation in Denmark between 1998 and 2015 observed that women aged 35-39 years and over 40 years have twice and even tripled the risk of CS, respectively, compared to mothers younger than 30 years [28].
The present study found an interesting result that secondary and higher educated mothers are more likely to have DCS than those who are illiterate. Highly educated women are aware of their health and concerned about the safety of health risk perception. Moreover, access to biased information and positive attitude towards caesarean birth are the reasons for preferring the DCS [11]. In line with the results of the current study, a meta-analysis focused on Sub-Saharan Africa revealed that maternal education was found to affect the delivery by cesarean section [20] significantly. In addition, women with a higher level of education are more susceptible to choosing DCS [29,30]. A study measuring the trend of cesarean section in Turkey observed that the rate of CS increase with the increase in mothers' education levels [31]. Moreover, a study of the global epidemiology of use of and disparities in CS revealed substantial differences in CS use within countries, especially among more educated women [32]. In contrast, several studies also found contradictory results that women with lower education are more likely to select a cesarian section [33,34]. This study revealed that religion substantially impacted the caesarean section in Ethiopia, and Muslims had the lowest likelihood of having CS compared to Orthodox and Protestants. A survey in a public university hospital in Dar es Salaam, Tanzania, found that religious belief significantly influences women's caesarean section attitude [35]. Moreover, social and cultural variables like education, religion, and wealth index were found to be substantial with DCS in several studies [34,36]. A qualitative study in Nigeria showed that religion plays a vital role in the caesarian section [37]. Furthermore, the religious provider influences the women regarding antenatal care (ANC) and the delivery landscape by promising 'faith' and 'divine protection' based outcomes other than child birthing skills [38,39], which leads women to a perilous situation. The total number of children born per woman is significantly associated with the cesarian section in Ethiopia. This study found that women with few children are more prone to have a delivery by caesarian section. A study in Bangladesh found that the total number of children and age at first birth are the most important factors for the cesarian section [40]. An investigation performed in sub-Saharan African countries revealed a significant reduction in CS with a per unit increase in the number of children [41]. A study found contradictory results to ours; women with numbers of babies less than 2 are associated with low caesarean section [42].
The mother's age at first birth was also found to be significant with CS in this country, and the women who give their first birth at a higher age were more susceptible to DCS than younger women. The study conducted in the UK observed that young women's age at first birth seemed to be protective of the later caesarian section [43]. A report from 1996 to 2021 in the United States of America (USA) leads to the same conclusion as the present study that a higher rate of CS was observed among the mother whose age at first birth was high (40-54 years) and lower CS rate (19.4%) was found among younger mothers [44]. A study based on Bangladesh Demographic and Health Survey 2014 (BDHS 2014) revealed that mothers whose age at first birth is greater than 20 years are more prone to have DCS following being overweight or obese [40]. The livelihood of the child also influences DCS. This research showed that mothers whose child is alive have a lower risk of having a baby with DCS compared to mothers who experienced their child's death. Mothers who had a previous bad experience with their children's death were more careful about their later delivery and were unwilling to take risks  [45]. This study found that the preceding birth interval significantly influences DCS in Ethiopia, and with the increase in the birth interval, the risk of having DCS tends to decrease. The mothers with preceding birth intervals of 21-30 months are more susceptible to DCS. An investigation identifying the prevalence and determinants of CS in Alexandria, Egypt, elucidated that preceding birth intervals substantially impact the DCS among Egyptian women [46]. A systematic review and meta-analysis on CS and pregnancy interval observed the association of birth interval with DCS [47]. Women with more preceding birth intervals had more likelihood of undergoing CS [48]. However, in addition to the features considered in this study, there may be other influential factors like maternal physical conditions, public-private health facility setting, and different environmental factors that could potentially affect the DCS, which is not included in this study and is the limitation of the present investigation. This investigation suggests further research determining the mentioned feature's importance in DCS. Moreover, the strength of this study is that the data used in this study are nationally representative, and the investigation accurately reports the statistical significance of the effect of various socio-economic, demographic, and cultural determinants on DCS.

Conclusion
In both developed and developing countries, caesarian deliveries have increased for decades. However, Ethiopia still lacks this service, which could mean missing out on potentially life-saving opportunities. Women's current age, educational status, religion, total children ever born, age of mothers at 1st birth, and preceding birth interval significantly impacted the delivery by caesarian section. Policy decisions will be needed for further national-level interventions depending on the results of this study. These factors should also be considered in health promotion programs to reduce unnecessary CS; Governments need to take the necessary steps to reduce caesarean rates and increase natural and healthy newborn delivery.